Anorectal and Pelvic Pain

Abstract

Although pelvic pain is a symptom of several structural anorectal and pelvic disorders (eg, anal fissure, endometriosis, and pelvic inflammatory disease), this comprehensive review will focus on the 3 most common nonstructural, or functional, disorders associated with pelvic pain: functional anorectal pain (ie, levator ani syndrome, unspecified anorectal pain, and proctalgia fugax), interstitial cystitis/bladder pain syndrome, and chronic prostatitis/chronic pelvic pain syndrome. The first 2 conditions occur in both sexes, while the latter occurs only in men. They are defined by symptoms, supplemented with levator tenderness (levator ani syndrome) and bladder mucosal inflammation (interstitial cystitis). Although distinct, these conditions share several similarities, including associations with dysfunctional voiding or defecation, comorbid conditions (eg, fibromyalgia, depression), impaired quality of life, and increased health care utilization. Several factors, including pelvic floor muscle tension, peripheral inflammation, peripheral and central sensitization, and psychosocial factors, have been implicated in the pathogenesis. The management is tailored to symptoms, is partly supported by clinical trials, and includes multidisciplinary approaches such as lifestyle modifications and pharmacological, behavioral, and physical therapy. Opioids should be avoided, and surgical treatment has a limited role, primarily in refractory interstitial cystitis.

Figure 1

Model for Chronic Anorectal Pain (upper panel), Interstitial Cystitis and Painful Bladder Syndrome (IC/BPS, lower left panel) and Chronic Prostatitis and Chronic Pelvic Pain Syndrome (CP/CPPS, lower right panel). Common to all conditions are peripheral (visceral) and central nervous system dysfunctions that often perpetuate each other. Our understanding of peripheral dysfunctions is largely derived from animal models rather than humans. In IC/BPS, the initial insult responsible for uroepithelial dysfunction is unknown. Thereafter, increased permeability may predispose to increased transepithelial diffusion of urinary constituents (e.g., potassium), which ultimately activate mast cells and T cells, leading to peripheral, then central sensitization. In CP/CPPS, bacterial infection may be the initial insult that activates a similar cascade of events. In chronic anorectal pain, a role for increased pelvic floor tension has been proposed. Chronic pain is amplified by psychological factors.

Figure 2. Algorithm for managing anorectal pain

Modified with permission from Bharucha AE, Wald AM. Anorectal disorders. American Journal of Gastroenterology 2010; 105(4):786-94.